Involutional Psychoses

INVOLUTIONAL PSYCHOSES, concept. A term grouping together a set of nervous and mental disorders associated with the period of decline or reverse development (involution) of the human organism. Initially, cases that chronologically coincided with the climacteric period in women attracted attention and underwent more systematic study. Thus, the term I. p. contains the idea of a biological process associated with changes in the endocrine system. The most typical is the so-called climacteric depression, or involutional melancholia. Endocrine changes and associated psychopathological pictures can develop in parallel, closely intertwining with arteriosclerotic processes; however, such a combination is by no means an obligatory rule in the pathogenesis of I. p. Most authors consider arteriosclerotic changes in the psyche as a special type of disease. Similarly, purely senile (abiotrophic) lesions of the cerebral cortex, which result in a relatively homogeneous picture of senile dementia, stand completely separate from I. psychoses. However, although all these psychoses of later age are theoretically different from each other in both course and main psychopathological signs, it should still be remembered that imperceptible transitions and numerous combinations of symptoms are observed between them. Even in normal conditions, involution in women (although Mendel also describes climacteric changes in men) gives rise to a whole series of nervous and mental changes. Along with headaches, rushes of blood to the head, and cardiac symptoms, insomnia, anxious-gloomy mood, irritability, suspiciousness, tendency to obsessive thoughts, etc., are often encountered. The described picture, which has not yet gone beyond the limits of physiological phenomena, is by no means based solely on organic changes in the endocrine apparatus, vessels, or nervous substance; in its origin, the psychic shock in the form of a distressing awareness of the decline of physical and mental strength, the experience of one's biological and socio-labor inadequacy, also plays a part. This psychogenic factor has varying pathogenetic significance in different cases depending on the constitution and general mental attitude of the subject. When the depressive symptoms mentioned reach considerable strength and persist in the patient for a longer or shorter period, it is customary to speak of involutional depression. This morbid form was initially isolated by Kraepelin into a special group (I. melancholia); only later, after the monograph by Dreyfuss, he unconditionally included it within the framework of manic-depressive psychosis. At present, some authors (especially Witte) have energetically come to the defense of Kraepelin's original opinion, considering I. melancholia as an independent disease in which the constitutional factor (belonging to the cyclothymic circle, which is by no means always provable) plays a secondary role compared to biochemical (exogenous) factors. This view is confirmed by the fact that in a number of other cases of I. p., the symptomatology presents completely different features. Sometimes paranoid symptom complexes come to the forefront (Kleist's I. paranoia, as well as some cases of Kraepelin's paraphrenia); here there appears to be a predominance of paranoid elements in the constitution of the patients, and disturbances in biochemical conditions, i.e., the exogenous factor, acts only as a precipitating factor, due to which the constitutional peculiarities became pathologically sharpened, and as a result, the disease developed. Secondly, purely catatonic states (late catatonia) are often encountered, and in these cases of I. p., one can suspect the existence of hidden schizophrenia in the patient. Finally, cases are by no means rare where I. p. takes the form of a reactive disease with hysterical symptoms, arising from some psychic trauma—the death of a close person, loss of employment, being on trial, etc. (I. hysteria of Witte, Geyer). In all these variations, with the common pathogenetic exogenous factor (involution), the main factor under the influence of which the disease picture is pathoplastically (Birnbaum) formed is the endogenous constitutional factor. Therefore, at present, the question of which group I. p. should be completely assigned to (to manic-depressive psychosis, to schizophrenia, to arteriosclerotic diseases, etc.) has lost much of its interest, since each individual case is a synthesis of a whole series of causes and accordingly a mosaic combination of symptoms. Such an interpretation of I. p. in the spirit of multidimensional diagnostics (mehrdimensionale Diagnostik Kretschmer's) and psychosis construction (Birnbaum) is currently accepted by a number of foreign (Bumke, Otto Kant) and Russian (Andreev, Geyer, Lyusternik) authors. The course of I. p. is as a rule slow, lasting for years. The prognosis is more favorable in pure depressions coinciding with the climacterium in women, less favorable in paranoid forms [Kraepelin's presenile delusion of inadequacy] and in catatonic forms. In the vast majority of cases, if recovery of health is observed, there always remains a certain vulnerability to the surrounding situation. The terminal states are rather peculiar: their characteristic feature is the impoverishment of the psyche, weakening of the emotional tone, narrowing of attention to those experiences that had agitated the patients during the period of illness. According to the research of Binswanger and Schaxel, I. p. affects people who are naturally unstable in nervous and mental terms. The question raised by Binswanger of congenital weakness (infantilism) of the vessels as a factor of important pathogenetic significance, sometimes causing a sharp decline in work capacity and mental energy in the presenile period, remains open for the time being.